Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 6604923-8905 | UT |
Y | 207QS0010X | Family Doctor - Sports Medicine | MD28274 | OR |
NPI | 1134252851 |
---|---|
Provider Name | Jonathan Clark Crist |
First Address | Portland, OR 97205-1902 |
Second Address | Tigard, OR 97223-6721 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/03/2007 |
Last Update Date | 06/11/2020 |